Is Neonatal Circumcision Clinically Beneficial? Argument Against

Robert S. Van Howe

Disclosures

Nat Clin Pract Urol. 2009;6(2):74-75. 

Clinical benefit is only one facet of clinical decision making; medical risks and financial costs also need to be considered. For example, many of the benefits espoused by advocates of circumcision would be more effectively achieved by penectomy, which has the additional benefit of preventing unwanted pregnancies. Of course, penectomy is too invasive, and is not a practical solution. Many of the "clinical benefits" lauded by advocates of circumcision include reduced risk of phimosis, balanitis, urinary tract infections (UTIs), genital cancer and sexually transmitted infections (STIs); however, evidence for these benefits are weak or nonexistent, and several alternatives to circumcision are available that are more effective, less invasive, and less expensive.

Phimosis is as common in circumcised newborns as it is in boys who are not circumcised. Topical steroids are effective in approximately 85% of patients,[1] and could eliminate the need for newborn circumcision to avoid phimosis. Balanitis is more common in circumcised than uncircumcised boys under age 3 years, but may be more common in uncircumcised older boys. The only published adult study of balanitis showed that a referral bias occurred among circumcised men: the control group had a 47.8% circumcision rate,[2] but the participants were from the UK, where the circumcision rate is around 21%. Balanitis can typically be treated with topical antimicrobials.

Newborn boys are more likely to have urinary tract abnormalities compared with girls, particularly in the first 6 months of life; however, many boys later outgrow these abnormalities. Observational studies have found that uncircumcised boys are at increased risk of UTIs during the first 6 months, but this finding might be a result of differential rates of prematurity, urine collection, false-positive urine specimens, and the frequency at which health care is sought.[3] In the absence of anatomic defects, UTIs do not require surgery and can be treated with oral antibiotics. The risk of UTI resulting in chronic renal disease is remote.

Of the 16 studies that assessed whether an association exists between circumcision status and the risk of cervical cancer in female partners, only 1 study found a significant association: a positive association in 1 study out of 16 studies is what would be expected by chance alone. Furthermore, a newly available vaccine against human papillomavirus (HPV) could prevent most cases of cervical cancer. With regard to a reduced prostate cancer risk after circumcision, the medical evidence that supports this association is weak.[4] The incidence of penile cancer is rare (0.8 cases per 100,000); two case–control studies in the US found that, when adjusted for phimosis, newborn circumcision was not associated with penile cancer.[5,6] The association between phimosis and penile cancer might explain why only half of patients with penile cancers are positive for HPV DNA, whereas nearly all patients with cervical cancer have HPV DNA. The other half of patients with penile cancer are probably associated with balanitis xerotica obliterans, the leading cause of true phimosis. Countries with very low circumcision rates, such as Japan, Norway, Finland and Denmark, have a lower age-adjusted incidence of penile cancer than the US. Low-risk sexual practices combined with screening and treatment of HPV infection and phimosis may be more effective and less invasive than universal circumcision.

The effect of circumcision on STIs is varied. Circumcision status has no consistent association with herpes simplex virus 2, HPV, gonorrhea, or chlamydia.[7,8,9] Men who are not circumcised, particularly in Africa, are at a slightly greater risk of syphilis and genital ulcerative disease, but have a lower risk of genital discharge syndrome compared with circumcised men.[7,8,9] As genital discharge syndrome is more common than genital ulcers, the overall rate of STIs is greater in circumcised men. STIs can be prevented and/or treated more effectively, less invasively, and less expensively with condoms and antibiotics than with circumcision.

Randomized controlled trials in Africa have shown some efficacy for circumcision in preventing HIV infection; however, these trials have bias for both participants and researchers (e.g. selection, lead time, expectation, attrition, intervention and length), improper randomization and early study termination, which amplified the lead-time bias. Each type of bias contributed towards overestimating the treatment effect. Advocates for circumcision believe that data from these randomized controlled trials, which recruited motivated, self-selected, well-compensated, high-risk adults, can be extrapolated to the general population in Africa and to infants; however, no studies have shown an association between HIV and neonatal circumcision. On the contrary, in a study of 52,143 heterosexual men attending a sexual health clinic, circumcised men had a greater risk of HIV infection than uncircumcised men.[10] Among developed nations, the US has the highest rates of heterosexually transmitted HIV and newborn circumcision. Condoms, when used consistently, provide 99% protection. HIV infections can also be prevented by choosing sexual partners responsibly and by treating STIs. For the cost of every circumcision performed in Africa, 3,500 condoms can be purchased. As condoms can provide nearly complete protection from HIV infection, circumcision adds little value.

Circumcision removes a complex, pentilaminar, specialized, junctional structure that contains nearly all the penis' fine-touch neuroreceptors. Not surprisingly, the foreskin is the most sensitive portion of the penis. Circumcision can reduce the sensitivity of the glans to fine-touch and vibration.[11,12] No wonder adults who undergo circumcision report less-satisfying sex, reduced sensitivity and erectile function, difficulty with intromission, and increased premature ejaculation.[13] Other commonly reported complications of circumcision include infection (1–3%), excessive bleeding (1–9%), meatitis (20%), meatal stenosis (5–8%), subcutaneous granuloma (5%), balanitis (16%), coronal adhesions (30%), skin bridges (2%), and phimosis (1–2%). Parents also request a repeat circumcision for cosmetic reasons in 2% of cases. Furthermore, circumcised newborn boys are 12 times more likely to acquire community-associated methicillin-resistant Staphylococcus aureus infections than uncircumcised newborns.[14] Other less-common complications of circumcision include septicemia, meningitis, Fournier gangrene, staphylococcal scalded skin syndrome, osteomyelitis, septic arthritis, tetanus, herpes simplex infection, empyema, pubic hair strangulation, denudation of the penis, glans amputation, urethral fistula, penile edema, pyogenic granulomas, acute urinary retention with acute renal failure, ruptured bladder, UTI or urine advancing in subcutaneous fascial plains, penile ischemia, pneumothorax, pseudoparaphimosis, pulmonary embolism, unilateral leg cyanosis, gastric rupture, myocardial injury and erythema multiforme.

Circumcision has no medical indication during the newborn period, and it is not the first-line preventive for any illness. Very few adult men choose to be circumcised, full disclosure is a rarity, and parental proxy consent for newborn circumcision is not valid.[15] No reason exists that can justify why circumcision cannot wait until the infant is old enough to choose for himself. As a public health measure, newborn circumcision in the US has failed to show a benefit in protecting against cervical cancer, penile cancer, STIs, and HIV.


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